Two years in review (one in stealth): a career transition

I had intended to post this around New Year’s day along with others who were sharing their reflections of the year past. And while an unexpected event delayed this posting to the point that it no longer seemed relevant, it has become clear to me that some of my readers have not been kept abreast of my career transition. I’d like to share the details of a whirlwind 2 years but it would be the length of a short novel, so here I take a brief look back and share a key point related to being a doctor in a startup in healthcare. 

At the end of 2017, there was little I could say about what I was up to. A year prior to that point in time, I had fully transitioned from practicing full-time primary care to eating, drinking and breathing start-up life. It was a crash course in product development and machine learning at a company that was in stealth mode. My family and peers had know idea what I was working on, but they were curious about the transition.

The first question people ask when I say I closed my practice to work at a startup is “Are you glad you’re working less hours?”

Let’s rewind. I was a young female Internal Medicine doctor working full-time in a large multi-specialty physician-owned Seattle practice, on call for my own patients every night except for weekends, when call was rotated. (I became more and more aware of this being a rarity when the jaws of those I relayed this to – primary care doctors themselves – would gape in shock.) I had good access, a fairly streamlined flow, and a great group of office staff (every doctor knows how critical and valuable this is). My physician-owned multi-specialty group gave the top floor of a beautiful new building in Seattle to the Internal Medicine Department. We Internists felt valued.

No doubt, the work was hard. The paperwork and messages were never-ending. I worked at least an hour and a half almost every night. But I knew what else was out there and how doctors in other health systems worked. I also explored concierge practice and felt the model didn’t align with my values or primary goals at the time. Direct Primary Care (DPC) was a strong consideration. Still, despite moments here and there of wondering what else was out there, I felt I truly had a pretty good thing going and appreciated the organization for which I worked.

It was, thus, serendipity that I came across a job description for a primary care doctor needed for a Seattle startup early in 2016, when I was neither burnt out nor actively searching for something else.

No, it was not about the hours.

 

 

 

Making the leap

Being observant of technology that came out of Silicon Valley, and mostly disenchanted with the leadership in the area at the time and the apparent values – I had been following the Theranos story closely –  I was skeptical but curious. Would a healthcare startup based in Seattle have a better culture? Would it last? 

In residency, one of my attendings had said that it took about 15 years of practice for doctors to really feel they’ve got it down, hit their stride. 15 years. Imagine hearing that now. By the time I answered this unusual start-up job description, I was already at 10.5 years of full-time work (and roughly twice the experience of colleagues working 0.5 FTE). Taking this new job was a risky move. Yet, I was always drawn to the tech side of things, particularly how it relates to usability in multiple areas. I had been dismayed by the way product after product was being developed in ways that kept missing the mark on being actually useful in the healthcare ecosystem or being short-sighted to the point that primary care doctors have to pick up the pieces.

So, after multiple talks with the CEO of the startup and verifying that both of us had an aligned vision, I went from running codes in the hospital to running code….or so I like to say fully tongue-in-cheek ever since a couple of our engineers showed me how to do a little of that.

 

Not breaking things

I learned firsthand what “moving fast” really looked and felt like, and more importantly, when to quickly hit the brakes on a plan and what to anticipate. Moving fast thoughtfully without breaking things is paramount to changing any system that touches people so intimately. This absolutely applies to healthcare, but not solely healthcare.

Failure is the best option….for learning

Though we are careful not to “break things” as a company, one of the most valuable parts of my experience thus far is learning how to fail. It turns out, trying not to fail 100% of the time is time and resource-intensive and unproductively aspirational, particularly when the path to doing something new has not been paved yet. I was forced to keep the risk-averse side (ubiquitous among doctors) in check. There are many articles and books that emphasize the importance of failure. Nowhere has the learning curve around this been as steep for me as in a startup. 

Looking forward

We’ve made big strides since we were a small company of 17. I am looking forward to what lies ahead in 2019 and beyond. No doubt it will include some uncertainty and some failures, but it will be mission-driven and exciting all the way.

Google’s new mental health tool is a good idea. But there’s more work to do.

Google has just come out with a mental health tool for those who query “depression” on its site. The Patient Health Questionnaire 9 (PHQ-9) is a series of nine questions that help assess depression symptoms. Doctors use it when screening for depression and use the results in conjunction with additional history from the patient to make (or not make) a diagnosis of Major Depression. Now anyone can access this same questionnaire on Google but is preemptively “encouraged to  talk to a care provider or doctor about what your score may mean for your overall health.” A link to the National Suicide Prevention Lifeline is also provided.

Depression, recently reported to be the world’s most widespread illness, has far-reaching implications when left untreated: from strain on personal relationships to disability and worsening of chronic conditions to an economic cost to society. As an internist, I saw many patients who were never diagnosed but wondered if they had depression. Some sought help even when their spouses or parents didn’t “believe” in depression and told them to “think positive” or “get over it.” I am thankful for those in the public sphere who bravely share their mental health struggles and help remove the stigma of mental health issues. And I applaud Google for designing a way to bring additional awareness to its users.

Google’s PHQ-9 feature is just a first step, however. Those who search the term “depression” likely represent a population who suspect or have been told they might have this diagnosis. But bringing awareness to the completely unaware is where the greatest impact can be made. I can’t count the number of times that patients have said – after diagnosis and when their depression is better controlled – that in retrospect, they likely had depression for many years and just didn’t realize it.  With platforms like Google, Facebook, Twitter and Instagram plus advancements in AI, we just might see that awareness occur sooner.

 

Is There Pressure to be Informed?

I recently had the opportunity to speak to employees of King County, WA about finding credible health information online. During the Q&A a few interesting questions were posed (rephrased here):

1. Does my doctor expect me to have looked up my symptoms online?
2. Does it help my doctor get to the diagnosis faster if I look my symptoms up online and come up with diagnoses, as well?

The person who asked question #1 told a story about reviewing some symptoms with his doctor at an appointment and being taken aback when his the doctor asked him, “And what did you find on the internet?” The patient had indeed looked up his symptoms online, and was surprised that his doctor knew. However, he was left wondering if he was actually expected to research his symptoms online before his appointments.

The second question is actally a good question that I had not considered but makes sense when looking at it from a patient’s perspective. Should patients do some “homework” prior to their appointments to help a doctor get to a diagnosis faster?

Regarding question number one, I often ask if there was something my patient thought he/she might have in order to make sure I address some concern that might be otherwise left unspoken during the visit. But I do not have an expectation that patients come in having “researched” their symptoms.

My answer to question #2 is based only on personal experience. It does not necessarily help me get to a diagnosis faster if a patient looks up his/her symptoms online. I have certainly had some patients who were able to come up with diagnoses that were correct. More often than not, though, the scenario in my office is one where a patient is concerned about the worst possible outcome (which, luckily, is not often the actual case). Then there are others who may have figured out their diagnoses but never mentioned it. As I do not have a well-studied answer to this question, I am open to hearing from physicians who might have had a different experience. That being said, I would not discourage a patient from using his own resources to find out more about his symptoms. However, he should keep in mind that after a detailed history (which is the part of the visit where the doctor gathers information from a patient’s story) and exam, the diagnosis could be very different depending on the actual details elicited and findings observed.

These two questions from the audience, however, brings to light our changing roles in healthcare. Certainly, the doctor-patient relationship has undergone yet another evolution with the concept of the e-patient, distant now from its paternalistic beginnings. But, in the midst of (at the end of?) the Information Age and, perhaps, heading into an “Understanding Age,” are there now new expectations placed on patients by others or by themselves?  Is there a certain degree of pressure to be an informed patient on those who may or may not be comfortable synthesizing this type of information? Is there an expectation that one knows everything about his/her own medical condition? Is there more pressure involved in just being a patient today? Sometimes, I think there is.

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The Doctor Will Really See You Now

“All the world’s a stage, and all the men and women merely players.”

– William Shakespeare

In our respective tragedies/comedies (depending on the moment), some individuals are better actors, revealing and hiding emotions with relative ease, portraying exactly the “I” that is scripted in their minds. Others, such as those who turn red at the slightest bit of discomfort, may try as they might but eventually have to give in to the transparency of their physiology.

Well, the playing (acting) field may have just been evened.

MIT’s Media Lab has engineered a remarkable pair of glasses “that are set to transform how we interact with each other” by accurately detecting very subtle facial cues that would be otherwise missed. The initial concept was born with the intention of helping people with autism pick up on these cues.

Inside the glasses is a camera the size of a rice grain connected to a wire snaking down to a piece of dedicated computing machinery about the size of a deck of cards. The camera tracks 24 “feature points” on your conversation partner’s face, and software developed by Picard analyses their myriad micro-expressions, how often they appear and for how long. It then compares that data with its bank of known expressions(see diagram).

From New Scientist http://bit.ly/kl0lvh

Roger Ebert (on Twitter) says, “These spectacles could destroy social life as we know it. And diplomacy.” But just imagine the possibilities within a doctor-patient interaction if a doctor could more easily detect skepticism or hope or fear or frustration. Perhaps, the use of these “social x-ray specs” would be limited in the case of a highly botox-ed face, but for the majority of patients, it could potentially enhance doctor-patient communication.

So, I say, “Where can I get one of these?”

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